March 2010

Return to football after Achilles tendon rupture

Only two-thirds of National Football League players ever come back, and those who do find their performance significantly affected. But research suggests a prodromal period may offer opportunities for early intervention.

Achilles tendon injuries have increased over the past few decades; however, the true frequency of Achilles tendon ruptures is unknown. These tears are usually the result of mechanical stress and intratendinous degeneration or pathology. The tendon can be affected by recurrent microtrauma with a low propensity to heal or degenerative changes within the tendon. Corticosteroids and fluoroquinolone antibiotics have also been implicated in tendon pathology.1 Mechanisms leading to tendon failure involve the rapid loading of an already tensed tendon. Proposed mechanisms of loading or overloading that result in an Achilles tendon failure include a dorsiflexion force to the ankle with a strong contraction of the triceps surae muscle, pushing off of the weight-bearing foot with the knee in extension, and a strong dorsiflexion force on the plantar flexed ankle.2 Between 75% and 85 % of ruptures have been associated with athletic activities or racquet and ball sports.1

Compared to the general population, athletes in the National Football League (NFL) are at increased risk for injury because the game involves explosive acceleration and sudden changes in direction.3 Very little is known about the epidemiology of Achilles tendon ruptures in the NFL. Utilizing data publicly available on the Internet, one retrospective review identified 31 Achilles tendon ruptures in NFL players over a five-year period (5.2 injuries/year).3 During the 2008-2009 NFL season, six players suffered season-ending Achilles tendon ruptures. Although the incidence of Achilles rupture is low, 0.93% per NFL game, nearly 36% of affected players never return to playing at the NFL level.3

Parekh et al used a player’s power rating as a measure of functional outcome in the evaluation of “skill players” in the NFL, which included defensive tackles, cornerbacks, linebackers, wide receivers, and running backs.3 The power rating is a measure of a player’sperformance using statistics gathered during game play, such as passing and rushing yards for an offensive player and tackles and interceptions for a defensive player. This study showed that 31 acute Achilles tendon ruptures occurred in NFL players between 1997 and 2002. The average age of a player sustaining a rupture was 29, with an average career before injury spanning six years.

Of the 31 players who sustained an Achilles tendon rupture, 21 (64%) returned to play in the NFL at an average of 11 months after injury. In the three seasons following their return, those 21 players saw significant decreases in games played and power ratings compared to the three seasons preceding the injury.

The percentage of players returning to play at the NFL level is consistent with a meta-analysis performed by Bhandari4 in 2002. The authors reported return to function rates of 63% for patients treated nonoperatively and 71% for those treated operatively. If we assume that all the NFL players were treated operatively, as would be the standard for young athletes, the return to play rate of 64% is slightly lower than the 71% reported in the meta-analysis. This difference could be attributed to the excessive demands placed on the operatively repaired Achilles tendon in NFL players combined with a body size, strength, and explosiveness that would further increase these demands.

The length of time to allow full activity after Achilles tendon repair is generally thought to be four to six months.4-6 The 11 months needed to return to play as a professional football player seems considerably longer. However, there is a major difference between allowing full activity and returning to play in the NFL. Even when the typical patient is allowed to participate in full activity, it does not mean that he or she is adequately rehabilitated to perform at maximal efforts. Studies to determine maximal improvement after surgical treatment are lacking in the orthopedic literature.

Furthermore, in the reviewed 21 NFL skill players who returned to play, there were significant decreases in games played per season (11.67 games per year pre-injury versus 6.17 games per year postinjury) when averaged over the three seasons before the injury and the three seasons after the injury.3 There were also decreases averaging nearly 50% in power ratings of the returning players for the three seasons after the injury compared to the three seasons before the injury. These data indicate that even in players able to return to their former level of play, the quality of play may suffer permanently.

Currently, it’s thought that operative treatment yields the best functional outcome for active patients.4-12 Intra-operatively, the appropriate resting tension of the tendon should be restored. Unfortunately, this is difficult to assess because there is no objective way to predict the actual resting tension of the tendon. Theoretically, if this tension is not restored, the force-tension relationship of the muscle tendon unit is disturbed, which would lead to a decrease in functional strength in the gastroc-soleus complex. This functional weakness could lead to more subtle loss of playing ability in high-demand athletes.

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Another possible factor that could have contributed to quality of play in athletes returning from Achilles tendon rupture is the rehabilitation protocol. Traditionally, patients have been treated postoperatively with a prolonged period of non-weight-bearing activity, ranging from six to eight or more weeks. More recently, studies advocating early functional activity have been published.9 These studies show improved functional outcome with respect to strength and decreased length of time to full activity. Despite having access to highly skilled rehabilitation protocols and personnel, professional football players in the U.S. may be limited in their recovery potential by an overly conservative treatment protocol.

Parekh et al3 also reported a decline in power ratings for certain skill players, specifically running backs and receivers, in the three seasons prior to their acute Achilles tendon rupture. It is possible that this observation suggests the presence of a prodromal period of Achilles tendinosis. Prodromal symptoms are reported by 15% to 20% of patients with eventual ruptures and include sharp pain in the tendon with activity, as well as reduced ankle dorsiflexion.13,14 More than half of 292 patients treated surgically for Achilles tendon rupture by Josza et al15 had evidence of preexisting degenerative changes in the tendon. Access to the NFL injury database would illuminate any symptoms these players may have been having prior to the season of their respective Achilles tendon ruptures.

Clinical implications

The treatment of acute Achilles tendon ruptures varies, and there is no uniformly accepted algorithm of care. Management ranges from nonsurgical to percutaneous, mini-open, and formal open repair methods. In general, studies show lower re-rupture rates and better functional outcomes with surgical repair than nonsurgical management.12 Some suggest that nonsurgical management should be used only when there is coaptation of the tendon ends with the ankle in 20° of plantar flexion as verified on ultrasound or MRI. However, for athletes wishing to return to pre-injury function as quickly as possible, surgical repair is the preferred option of choice. Some have used an accelerated protocol with range-of-motion exercises 72 hours after surgery, a posterior splint for two weeks, and subsequent ambulation in a hinged orthosis. Six weeks after surgery, use of the orthosis was discontinued, full weight bearing was allowed, and progressive resistance exercises were initiated.6 This protocol is in comparison to patients with Achilles tendon ruptures treated nonoperatively, with mean casting time of 8.3 weeks prior to beginning rehabilitation.7 However, higher rates of complications do occur with surgical treatment of acute Achilles tendon ruptures.7 The most common complications from surgery include wound complications, adhesions, altered sensation, and infection. Less invasive surgical methods have been developed to minimize these complications.

Historically, re-rupture rates were higher with percutaneous and mini-open techniques compared to open repair, but recent literature suggests equal rates.11 However, coaptation of the tendon ends is not ensured with minimally invasive techniques. In addition, MRI findings show that it takes longer for the tendon gap to disappear with percutaneous methods (11.6 weeks) than with open repair (8.6 weeks).8 Some surgeons use endoscopy in addition to their minimally invasive technique to confirm that the tendon ends are approximated.10 Studies comparing percutaneous repair to open repair show no difference in re-rupture rates, but the infection rate is higher with open repair.5

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Rehabilitation after surgical repair is trending over the past decade toward earlier motion and weight bearing. This trend is somewhat based on knowledge of improved strength and gliding of tendon repairs following hand surgery after rehabilitation protocols with early motion and controlled loading. Such ideas of early motion have also been popularized in anterior cruciate ligament reconstructions. In a retrospective review, Shelbourne16 showed a reduction in loss of knee motion and strength after an accelerated rehabilitation program following ACL reconstructive surgery; however, in a more recent prospective randomized analysis, Beynnon et al17 showed no difference in functional performance between the study’s two groups.

A goal of surgical Achilles treatment is to prevent tendon elongation, which can be responsible for decreased power of the gastroc-soleus complex, by lengthening the musculotendinous unit. Patients with a surgically repaired Achilles tendon, who are placed in a brace and allowed early motion from neutral to plantar flexion, have less tendon elongation than do patients who are treated in a cast.18 Studies looking at immediate weight bearing have shown an earlier time to normal walking and stair climbing, but not in return to sports.19 Suchak et al20 noted an improvement in outcome scores, enhanced quality of life, and activity level in the early postoperative period with a weight bearing as tolerated protocol; however, no difference was found at six months. Studies have also shown that formation of adhesions and sural nerve deficits were less frequent with use of functional rehabilitation versus immobilization postoperatively.21,22 One concern in an early motion and weight-bearing protocol is the potential for increased risk of re-rupture if patients prematurely return to strenuous activity. Other authors have shown no significant differences between patients treated with early functional treatment and those with immobilization with regard to pain, stiffness, subjective calf muscle weakness, footwear restrictions, range of ankle motion, calf muscle strength, or overall outcome.21,23

The decrease in power ratings seen in the NFL players could suggest that they are returning too soon, before rehabilitation is fully complete, that the ultimate strength of the healed repair is less than its pre-injured state, or that the musculotendinous unit may have lengthened. Based on the literature, the best treatment for athletes would consist of surgical repair, with an open, mini-open, or percutaneous technique, focused on tendon apposition and proper musculotendinous unit tensioning followed by a functional rehabilitation program involving a progression of increasing motion, weight-bearing, and strengthening exercises. Typically, return to sports is allowed at six months. Even after return to activity, it may be necessary for patients to perform more intense strength training of the repaired tendon and gastroc-soleus complex prior to full participation in their sport.

Acute Achilles tendon rupture can be a career-ending injury for athletes. The question arises as to whether we should be more aggressive in treating a prodromal period in an attempt to avoid a subsequent rupture. This treatment would be initiated by pain and symptoms experienced by the athlete. Initial evaluation should consist of taking a history and performing an exam. Ultrasound evaluation or MRI may be considered to evaluate the presence of tendinopathy. If tendinopathy is not present and a prodromal period is suspected, then initial treatment should consist of activity modification, nonsteroidal anti-inflammatory drugs (NSAIDs), a heel lift, and physical therapy concentrating on eccentric strengthening of the gastroc-soleus complex. While some stretching may be beneficial, aggressive stretching may aggravate the symptoms. Further treatment could include vasodilation with topical nitric oxide, which has been shown to reduce pain and improve outcomes in cases of chronic tendinopathy.24,25 Other investigational treatments include pulsed electromagnetic fields and extracorporeal shock-wave therapy. If tendinosis is present, the treatment would be the same; however, further surgical options would include percutaneous longitudinal tenotomy and open debridement.

Achilles tendon ruptures can have dramatic career implications for the athlete. These are complex injuries, with surgical intervention being only the first step in the recovery. The ultimate return to function is based on a variety of variables, some of which are controllable by the surgeon, athlete, and therapists. Ultimately, more research will be needed to examine these injuries and their outcomes to determine the ideal protocols for treatment of the competitive athlete.

Khalid Shirzad, MD; John D. Hewitt, MD; and Carter Kiesau, MD, are fellows of foot and ankle surgery in the division of orthopaedic surgery at Duke University in Durham, NC. Selene G. Parekh, MD, MBA, is an associate professor of surgery in the same division.

16 Responses to Return to football after Achilles tendon rupture

Great Article! I recently had an achilles tendon rupture while playing basketball and i was looking for some evidence about the “return to sports rate” of professional sport athletes… the rate of about 2/3 gives me some hope to be able to get back to my old strength, also to know that they returned only after an average of eleven month helps me to evaluate my progress! Kaia from Germany.

Yes great article I also had an Achilles tendon rupture while playing cornerback.The doc told me I need to have a six months break but I know it will require more than that to be competitive again
Rabs from France

i had surgery on my right leg 8 months back..now i can walk as like bfore but still i cant run.. somehthing tight feeling on my tendon when i try to force on my leg. This rupture happened to me just a day bfore our group league football and couple of week left for my marriage.. Aftr surgery i married on the fixed date but it was not a grand functio as we expected. anyway..i hope for the best and this article gave me some more energy and will do more workouts to get it well asap.

I’m doing non-surgical repair in a cast. Doc says I don’t have a complete rupture, just a partial tear. I was trying to get an idea how long I’d be on the DL. Looks like it will be longer than I thought. Thanks for the article!

Thanks for the great article. This is what I need to know. I like how you explained the average activity player vs pro player. I had my surgery 2 weeks ago today, so I have 4 more weeks of no weight, then I’ll be in a boot and off to rehab. I play semi pro football, so hopefully I’ll be ready to go next year. I’m also looking into getting massages more regular on ‘both’ achilles tendons to pervent them from being tight.

28th May 2012, is the date I had a complete tear of my Achilles, it happened identically to David Beckhams injury at Milan. The specialist advised against surgery so I am 3 weeks into a cast set equinus. I think another 3 weeks before it is removed, but the last few days I have felt confident enough to want to put weight on it…… I feel like the cast is holding me back.

I think by the time the cast is removed I will be going stir crazy but I know this is so etching that perhaps can’t be rushed.

Greetings,
I had the complete tear happen. Popped while playing bball and I’m no weekend warrior either. I opted for the non surgical .. 20% of those that have surgery, have some complication of nerve or skin or infection. and the numbers were similar on re-injury stats after 12 month period. either way you do it… Im 41 yrs old . ball ride bike hike.. so I took the cast seriously. May 24th to like August 8th, I stayed over 3 months in the cast . if it itches.. use a clothes hanger to scratch but dont cut yourself in doing so.. stay off the foot.. I moved so I didn’t have a rehab set up. use your crutches. even when the cast is off …you might slip and put your foot down by mistake and rip the tendon again. I just have doubts about the tenacity of the tendon. The first time took me by surprise so I don’t know how far to push it. I just got the barefoot shoes by vibram.. awesome for the foot and ankle .. that has made the most difference of all strength and tension techiques. just walking in the flat shoes.. crazy… hey good luck out there….

Great article. Im 32 and Im two weeks in on my 100% tear of my achillies tendon. I had surgery to repair. I thought this injury would take time. Will get lots of rest and will use those crutches.
Thank you and a quick recovery to all. JAS

This is a very insidious injury. I opted for no surgery and 5 months and 1 week later I am able to walk again with power but still limp slightly. I can’t run even 2 meters. I’ve always been athletic and at 57 still compete in mountain biking and tennis. It was while playing tennis that this happened. Unfortunately, I am now so afraid of it happening again, especially to the other side, that I doubt I will ever play tennis again. Does anyone else feel the same?

I’M a 17 years old female and my dream is to become a professional tennis player. I ruptured my Achilles tendon about 8 weeks ago and it is still in a calf. The doctors were somewhat surprised that I suffered this injury since it is more common in older middle-age males. I am wondering if I will make a full recovery and how long it would take before I could start playing again. Can anyone advise me on the rehab exercises? Thanks and all are welcome.

Hi, I am a 29 year old male. I ruptured my right achillies tendon about 5 months ago. I had an ultrasound and was told i was lucky as it was a partial tear. I was advised against surgery and told to go the conservative route. I had the boot on for 9 weeks and started Physio 4 weeks after rupture. It’s been about 5 months now I am off the crutches and can walk but with slight limp. I cannot run yet. And I have noticed a lump appearing at the back of the tendon. Anyone had experience of this? Also I am not able to do the one legged heel raise on the injured leg. Any thoughts would be greatly appreciated. Good luck to everyone with their recovery.

Did you compare the data to the careers of players of similar experience who did not suffer achilles heel ruptures? You said that “The average age of a player sustaining a rupture was 29, with an average career before injury spanning six years.” In the NFL, 29 is pretty close to retirement age for most players, and in any case one would generally expect a drop-off in performance relative to what they had done a few years earlier, so I am curious as to how much the injuries reduced what would have been expected of their career had they not suffered the injury. When you factor in the year that they have to take off for rehab, that means that they didn’t try to return from the injury until they were 31; injury or no, many players retire by then anyway. Was this ever accounted for in analyzing the data?

I’m now 9 months post-surgery for an achilles rupture and I was treated conservatively (cast for 6 weeks, walking boot for another 6 weeks). I’m 36 years old, was in great shape and did it playing basketball. Some people have reported still limping at 6 months out and not being able to run. I was also the same. The limp didn’t go away completely until about 7.5 months post-op. But I can say that at 9 months I feel really good and I’m back to running around 20 miles a week. Once you get back into some regular activity, progress really starts to pick up rapidly. Funny thing is that now my left achilles is healing well I’m more worried about my right achilles since it took a pounding while I was compensating for the left. Hang in there if you have the injury. It will get better.

I had a complete rupture of my Achilles’ tendon on my left leg while playing basketball in July 2012. I opted for the surgery and read as much as I could on the topic. I went through therapy after a few months. Basically worked a lot on stretching and balance to restore muscle memory. I too was and still am worried about my right tendon and possibility of a re-rupture on the left. It’s crazy how this injury gets in your head. Having said that, a year post surgery, I ran a 5k. My point is, don’t give up. I probably won’t be balling as hard as I once did, but I have stepped back on the court. I also have a lump where the tear once was, but that’s normal. It’s scar tissue and has lessened with time. I added a lot of protein to my diet as well as vitamin c. I also ate gelatin. I guess they say that it helps with the building blocks of tendon collegian. 16 months post surgery now and I can run and do whatever I want. I’d say I’m 90% of where I was. The only lasting effect has been the psychological aspect. Good luck all!